Prevention of Medication Errors in High-

Acuity Settings

By:
Vanessa Bustos, Maddi Eckert, Kelly Mellody, Alexandra Montenegro, Holly Ochieng, Kevin Olivarez
Erin Tansey, Kylie Wong, and Sobia Zehri

Lab Group F
 Medication Errors
● Medication ● Mortality/frequency:
administration is a high- ○ 450,000 times
risk activity that nurses annually
perform daily. ○ Approx. 7,000
preventable deaths in
● It is estimated that 5-27% the U.S each year
of medication orders ● Cost: $3.5 - $29 billion
written result in errors each year
 Significance for Nursing Practice
Nurses are the last and final
“barrier” between medications and
the patient. Decreasing medication
errors will improve the following in
nursing practice:
● Improved quality/safe patient care
● Improved patient satisfaction
● Decreased mortality/morbidity
rates
● Decreased hospital costs
● Future progression:
implementation of distraction free
medication practices may be able
to be transferable to other high
risk activities
 PICOT QUESTION
In high-acuity settings, does P: high acuity patients
the use of signage mandating I: use of signage
a distraction free zone in the C: no signage
medication room, versus no O: reduction in medication
use of signage, reduce errors
medication errors over a six- T: over a six-month period
month period?
Current practice
Nationally
● 100,000 lives campaign
● The Joint Commision Goals
○ Identifiers, Right drug and dose, Right information
○ Speak up campaign

Statewide
● Arizona Hospital and Healthcare Association; HIIN

Local
● Banner and Carondelet programs and participation
○ “Its okay to ask”
○ Medication forms
○ Usage of signage
Current Literature Findings
● One cause of medication errors was distractions when
drawing up and administering medications
○ Determined to be a distraction if the conversation was
not relevant to the medication administration
○ When the nurses are distracted by their colleagues or
patients and their family members it can lead to errors.
○ Most common distractions were call lights and patients’
families
○ In another hospital it was found to be conversation
between nurses
● Signage and vests were utilized in order to remind nurses of a
“no distraction zone”
○ This intervention reminded other staff members, the
nurse administering the medication and family
members.
 How Many Distractions Do Nurses Have?
● 57 out of 100 medication administration
processes were interrupted.
○ After the intervention it decreased to 15/100
● 20% of the time the nurse spends during the
medication administration process is spent
dealing with interruptions
● 58 out of 100 medication administrations had
interruptions
○ Decreased to 24/100 with vests
● PCCU medication administration was
interrupted 15% of the time
Results of the Interventions
● Nursing students were found to be more compliant
than RNs
○ Nursing students 75-80%
○ RNs 50-70%
● The studies all showed a decrease in medication errors
○ 66% decrease in medication errors in 3 Dutch Hospitals
○ 79.2% decrease in medication errors in CVICU and
several months went by where no medication errors
occurred.
○ 83% and 53% decrease in two PCCUs
○ 50% decrease over a 3 month-period
● Medication errors decreased and nursing compliance
improved
Strengths
● Methods show a direct cause and effect relationship between interventions and
medication errors/interruptions
○ Measured interruptions and medication errors before and after implementing interventions
● Studies were based on prior research studies
○ Methods and interventions used were based on previous studies
● Training and education performed before implementing intervention
○ Lead to more accurate results becauses nurses understood interventions fully
○ Education also given to unit staff, health care providers, patients, and families
■ Helped prevent interruptions
Limitations
● Studies were conducted over short time periods
○ Long term consequences are unknown
● Interventions were bundled
○ The direct effect of implementing a no interruption zone on medication errors is unknown
● Setting and samples limit generalizability
○ Studies conducted in specific settings: cardiothoracic step down unit, stimulated chemotherapy
ambulatory setting, etc.
○ Convenience samples can misrepresent the population
● Observation used as a data collecting method
○ Hawthorne effect: participants in a research study modify their behavior because they know they
are being observed
○ Example: nurses paid more attention to medication administration
Best Practice Recommendations
Redesign of the workplace environment and strategies for reducing interruptions or
distractions during medication administration should be implemented in order to
decrease errors in preparation and administration

● Disruptions can result in “capture error”

○ Error that occurs when two different cognitive sequences overlap, removing attention from a task
that requires problem-solving and effort
○ Attention is taken away from medication administration, resulting in decreased cognitive effort in a
task that requires attention
● Much of the research found in this study implicated distractions and
interruptions in over 45% of medication errors.
(Yoder, Schadewald & Deitrich, 2015)
Best Practice Recommendations
Quiet zones should be clearly marked, and healthcare professionals should be
educated on the importance of no conversation during medication prep. Nursing staff
should also wear a vest or sign indicating a quiet medication preparation area.

● Where staff was compliant, medication errors were reduced over a three-month
period
○ In areas where staff continued to talk during medication preparation or
administration, medication errors were increased

(Yoder, Schadewald & Deitrich, 2015)

Best Practice Recommendations
As part of a comprehensive safety program, the Institute of Medicine recommends
that healthcare organizations adopt strategies to reduce interruptions during
medication administration.

● Implementation of strategies to reduce interruptions during medication

administration resulted in decreased avoidable interruptions and increased
patient safety over an 18-month period.

To ensure ongoing compliance, the Institute of medicine recommends the

implementation of periodic observation of nursing staff to ensure compliance with
distraction and interruption-free medication areas.

● Periodic observation allows for accurate error reporting, as opposed to solely

relying on nurse self-reports
(Flynn et al., 2016)
Best Practice Recommendations
Implementation of distraction-free medication practices may be applicable, and should
be considered in other high-risk activities to prevent patient harm.The use of
distraction-free practices should be implemented for other national patient safety goals
to enhance work environments.
● Across all units where “red-zone” distraction-free practices were implemented,
there was a notable reduction (33.3%-79.2%) in medication errors
○ The implementation of nurse ambassadors aided in driving change on each unit
● Evaluation is ongoing to assess the effects of distraction-free practice during:
○ Blood product administration
○ Endotracheal tube care
○ Central line placement and care

(Connor et al., 2016)

Implementation to Nursing Practice:
Month 1: Month 2:
● Charge nurses on the ICUs will ● RNs on the ICUs will attend a 2-hour
be asked to monitor medication
information session about the financial
administration during peak
and human costs of medication errors.
medication administration times
once a week for two hours over a ● Plans for the upcoming intervention will
month period. be disclosed.
● The registered nurses on the ● They will be also informed of the results
units will be blind of the of the observations made by the charge
monitoring. nurses during the last month.
● A sum of the medication errors
and number of distractions
witnessed will be calculated.
Month 3:
● The signage in the medication
rooms and the medication
administration vests will be
distributed to medication
rooms in the ICUs.
● The RNs will begin using the
vests and following the
directions on the signs in the
medication rooms at this time.
Month 4:
● Four weeks after implementation,
an email will be sent to the RNs
requesting their input and opinion
about the intervention.
● Their feedback will be
anonymous.
● They will be given 7 days to give
feedback.
Month 5: Month 6:
● The RNs will attend a two-hour
● Charge nurses will randomly reassess the
information session and be told the
RNs’ usage of the medication
results of the reassessment.
administration vests and their adherence
● The RNs will be told of any changes
to the directions on the signs.
that were made to the intervention in
● The reassessment will occur during peak
response to the feedback provided by
medication administration times, once a
the RNs during month 4.
week for two hours, for three weeks.
● The anonymous feedback provided by
the registered nurses via email will be
analyzed. The charge nurses will adjust
the intervention to address the RNs
concerns as necessary.
 Cost Analysis
Signs:
Vests:
vistaprint ® Supplier: Full Source ®
2, 22” x 28” signs per medication
administration room in every ICU in Vest: OccuNomix ECO-GC Class 2
the hospital. Value Mesh Safety Vest - Yellow/Lime
- $5.99 / Each
Each poster is $16.78.
3 vests per medication room = $17.97
2 posters = ($16.78)(2) = $33.56
Shipping: $8.00 Shipping: $5.99

The signs in each medication Price to stock vests in each medication

administration room would cost room: $23.96
$41.56
Total cost of intervention per medication room: $65.52
Cost Analysis Continued..
● Staff education: Each staff member will attend 4-hours worth of paid education
during the 6-month intervention.
● Average hourly salary of a nurse in Tucson, AZ: $27.50
○ ($27.50)(4) = $110.00 to train each registered nurse on the unit.

What this intervention has cost other facilities:

● A similar intervention cost a hospital $891.00 the first year and $283 on average
annually, each year thereafter.

(Wines, 2013).
Sample Cost Analysis:
Year 0 Year 1 Year 2 Year 3
Red Vests $320 $80 $80 $80
Medication Checklist $39 $39
Education of Nurses $434 $66 $66 $66
Signage $98 $98
Total Costs $891 $146 $283 $149
Cost of Medication Errors:
● Preventable medication errors affect 7M patients each year
● Cost $21B annually
● Each medication error costs the hospital $8,750.00
● 5% of hospitalized patients experience an adverse drug event related to a
medication error
● 50% of medication errors are preventable
● Most common causes of errors:
○ Poor communication
○ Medical abbreviations
○ Poor technique
Risk vs. Benefit
Risks medication errors cause:
● Institution:
○ Increased hospital spending
■ Preventable medication-related errors cost an estimated $3.5 billion a year in the US.
○ Increased mortality rates
■ Medication errors are the 8th leading cause of medical-related deaths in the US.
● Nursing:
○ Risk losing their license

■ Nurses experience as many as 14 interruptions per hour and 21% of these interruptions
occur during tasks such as medication delivery and verification.
○ The therapeutic relationship with the patient is hindered
● The patient:
○ Increased hospital stay
○ Experience adverse reactions (Yoder, Schadewald, & Dietrich, 2015).

○ Increased medical bills

Risk vs. Benefit cont..
Benefits of implementing a “distraction free” zone during medication administration:
● Institution:
○ Improvement in quality of care
■ Interventions, such as the MedSafe protocol medication administration have demonstrated the
potential for reducing errors from 52% to 22% (Yoder, Schadewald, & Dietrich, 2015).
○ Decreased incidence of medication error related mortalities
○ Decreased hospital cost
○ Improved hospital ratings and overall patient satisfaction
● Nursing:
○ Reminds staff to limit distractions during the medication process
○ Allows time to gather the medications and materials needed without feeling rushed
○ Allows time to research the medication, calculate the appropriate dose, and determine if compatible
with other medications
(Yoder, Schadewald, & Dietrich, 2015).
Risk vs. Benefit cont..
Benefits of implementing a “distraction free” zone during medication administration:

● The patient:
○ Patient safety
■ Patient safety is a healthcare priority
○ Improved patient satisfaction
■ Scores related to patient perceptions of quality and safety increased approximately
40% during project implementation of the Safe Zone trial.
○ Limits the amount of distractions caused by patients
■ Sources of most frequent distractions include the patient talking to the nurse, call
lights, and conversations being held by other people within the unit.

(Yoder, Schadewald, & Dietrich, 2015).

Evaluation: SMART Outcomes
● Reduce medication errors 60% over a six-month period through the use of a
distraction free zone in medication rooms via signage on medication room walls
and medication administration vests.
● Improve patient safety by reducing medication errors 60% over a six-month period
through the use of a distraction-free zone with signage on medication room walls
and medication administration vests.
● Distractions will decrease 50% during medication administration after the
implementation of signage in the medication room (both on walls and on vests)
over a 6-month period.
● Decrease medication errors by reducing conversation 80% during medication
preparation via quiet zone signage on vests and walls of the medication room for 6
months.
Summary
● Medication error incidence is a concern within the healthcare field.
● Health care institutions are developing a culture of high reliability to prevent
medication errors.
● Issue
○ Patient safety
○ Medication errors
○ Distractions

http://blog.mission-health.org/2016/07/21/quiet-environment-healing-environment-respect-sash/
Summary
● Best Practice
○ Culture
○ Use of Indicators
○ Nursing Ambassadors
● Supportive Studies
○ Additional Practices
○ Red Zone Initiative

https://www.nursingtimes.net/the-effectiveness-of-drug-round-tabards-in-reducing-incidence-of-medication-errors/5018770.article
Summary
● Cost Analysis
○ Equipment cost
○ Training cost
○ Importance
● Application to facility
○ Initial data gathering and RN education and
discussion about intervention
○ Implementation of intervention and RN
feedback
○ Post intervention data gathering and results

https://www.nursingcenter.com/journalarticle?Article_ID=1692089&Journal_ID=54030&Issue_ID=1691929
Summary
● Benefits
○ Quality of care for the patient
○ Healthcare facility
○ Nursing consideration
● Risks
○ Patient
○ Cost
○ Nursing Career

https://www.sfgate.com/health/article/Prescription-for-success-Don-t-bother-nurses-3282968.php
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